Hospital Course
On presentation, the patient was found to have incompatible blood due to
warm autoantibodies, precluding transfusion. On the second day of
hospitalization, hemoglobin decreased to a nadir of 5.3 mg/dl.
Rheumatological panel (Table 2) showed elevated IgM, positive rheumatoid
factor, and anti-dsDNA. Positive direct antiglobulin test was positive
for IgG and C3, and a presumptive diagnosis of acute warm hemolytic
anemia complicating anemia of chronic disease was made. Following this
diagnosis, the patient was given a single 125mg dose of
methylprednisolone sodium succinate followed by high-dose oral
prednisone (40mg/daily).
Nevertheless, the patient continued to deteriorate, developing worsening
fatigue, pre-syncope and palpitations despite steroid administration and
stabilized hemoglobin. At this time, the treating team was informed of
the positive IGRA two years prior and lack of follow-up treatment for
latent TB. Due to concern for TB re-activation, chest imaging was
performed, along with repeat IGRA and infectious disease consult. While
IGRA was negative, chest radiograph showed a small, laterally located
lesion in the upper right lobe and focal consolidation of the upper left
lobe (Figure 1). Isolation precautions were started, and empiric
broad-spectrum antibacterial therapy was initiated for presumed
pneumonia. CT imaging of the thorax showed necrotizing bronchopneumonia
affecting the left upper lobe (Figure 2) with additional necrosis of the
right middle lobe. Mild prominence of mediastinal lymph nodes was also
appreciated. Additional tests for etiology included histoplasma
antibodies, legionella urine antigen, as well as general mycology and
bacteriology, however, antibody and culture tests were all initially
negative. Furthermore, there was no evidence of neoplastic disease.
Because serologic testing was negative and sputum samples were
unproductive despite sputum induction with hypertonic saline, a
bronchioalveolar lavage (BAL) was performed. The sample demonstrated 4+
acid-fast organisms. Follow up PCR testing of BAL sample was positive
for Mycobacterium tuberculosis and rifampin, isoniazid,
pyrazinamide, and ethambutol (RIPE) therapy was initiated. The patient
was discharged shortly thereafter. Over the next 9 months, the patient
had one episode of seronegative arthritis, and two additional episodes
AIHA. TB was well controlled on RIPE therapy in these admissions,
without evidence or reactivation.